Transcription

1 FEATURES Members can choose to go to ANY PROVIDER or HOSPITAL they choose. Out of pocket expenses will always be lower when using in-network providers and facilities. To find a provider visit All routine or scheduled medical care must be provided through CDPHP providers. In an emergency or urgent care situation, non-participating providers may be used as long as it is medically necessary. All routine or scheduled medical care must be provided through MVP providers. In an emergency or urgent care situation, non-participating providers may be used as long as it is medically necessary. NETWORK OF PROVIDERS In-Network benefits are paid when members choose to use the Blue Shield national network, which includes over 686,000 Providers, and over 6,000 hospitals. When using out of network providers, benefits will be paid under the Out-of-Network schedule of benefits. CDPHP has a comprehensive network of providers & hospitals in the 24 county service area in NYS. To find a provider visit MVP s service area of providers & hospitals extends to 27 Upstate NY counties. To find a provider visit DEDUCTIBILES & CO-PAYMENTS Out of Network: Deductibles Individual: $200 Two Person $300 Family $400 After deductible is met members pay 20% coinsurance. There are no deductibles. There may be a $15 co-pay for some services as indicated in this comparison. $50 copay for emergency room and $25 copay for participating urgent care facilities. There are no deductibles, $15 co-pay for some office services as indicated in this comparison. $50 co-pay for emergency room and a $15 co-pay for urgent care facilities.

3 CHIROPRACTIC SERVICES HOSPITAL BENEFITS INPATIENT Room & Board Surgery 2 nd Surgical Opinion Physicians Visits Maternity Newborn Care ; 15 visits per calendar year. No referral. after deductible, 15 visits per calendar year, not subject to review. In-Network: Out of Network: 100%, after $100 copay (semi-private room) In-Network: Out of Network: Out of Network: 20% co-insurance Out of Network: 20% co-insurance In-Network: Out of Network: 20% co-insurance In-Network: Out of Network: after $15 co-pay. for unlimited days and dollar amounts when medically necessary. after $15 co-pay. after $15 co-pay to participating provider. for unlimited days and dollar amounts when medically necessary. after $15 co-pay.

4 HOSPITAL BENEFITS OUTPATIENT Surgery Diagnostic X-Ray & Laboratory Services Emergency Care Pre-Admission Testing Radiation Therapy Chemotherapy Physical Therapy Speech Therapy Out of Network: 80% UCR In-Network: $50 co-pay applies to non-emergency diagnosis. Paid in full with emergency diagnosis. Out of Network: 20% UCR ; 40 (In & Out of Network combined) visits per year for home care including home infusion therapy. after deductible. 40 visits per year. ; 40 (In & Out of Network combined) visits per year for home care including home infusion therapy. after deductible. 40 visits per year. $15 co-pay/day/facility $75 co-pay $15 co-pay Diagnostic labs covered in full; $15 copay per visit for X-ray services. when medically except for $50 co-pay necessary after $50 co-pay when when not followed by hospitalization. treated in the emergency room not Co-payment waived if admitted. $50 followed by hospitalization. Co-pay co-pay applies for out of network. waived if admitted. Up to 120 days per unrelated diagnosis per calendar year. Limited to services which will produce significant improvement within the 120-day treatment period. $15 co-pay/visit. Up to 60 days per unrelated diagnosis. $15 co-pay per visit. $15 co-pay per visit; 30 day s maximum per member per year; combined benefit for PT/OT/ST. $15 co-pay per visit; 30 day s maximum per member per year; combined benefit for PT/OT/ST.

5 MENTAL HEALTH CARE PRESCRIPTION DRUGS DURABLE MEDICAL EQUIPMENT & PROSTHETIC APPLIANCES AMBULANCE SERVICE MUST BE MEDICALLY NECESSARY & REQUIRED AS A RESULT OF AN EMERGENCY SKILLED NURSING FACILITY ROUTINE EYE EXAMS & EYEWEAR coverage after deductible. In-Network Only: RETAIL: 20% co-insurance MAIL ORDER: 16% co-insurance In-Network: 20% co-insurance coverage; Air ambulance only covered in network. coverage; 60 days per calendar year. Out of Network: 100% after $100 copay; 60 days per calendar year. (annually) Empire Vision Frames: $20 co-pay; 100%, Contacts: $45 co-pay; Out of Network: $35 co-pay after deductible is met. Frames: $35 allowance after deductible. Contacts: $90 allowance after deductible. Inpatient covered in full. Outpatient $15 co-pay Retail - $5 generic/$20 brand preferred /$35 brand non preferred at any participating pharmacy, per 30 day supply. Mail Order - for maintenance drugs 90 day supply $12.50/$50/$ % co-insurance; must be ordered by a participating provider and approved by CDPHP. $50 co-payment for a licensed ambulance. for up to 90 days per calendar year in a semi-private room in lieu of further hospitalization; must be ordered by a participating physician after hospital stay for the same accidental injury or illness. Yes. Every 24 months. $15 co-pay. In Network Only. Inpatient covered in full. Outpatient $15 co-pay Retail - $5 generic/$20 brand preferred /$40 brand non preferred at any participating pharmacy, per 30 day supply. Mail Order - available for maintenance drugs 90 day supply $10/$40/$80. after 20% coinsurance for purchase or rental of DME. Must be authorized by participating MVP physician. in lieu of hospitalization for 60 days per calendar year when pre-approved by MVP. once every two years after $15 co-pay. Frames: N/A Contacts: N/A

6 Provider Freedom of Choice YES NO NO Coordination of Benefits YES NO NO National Network Over 686,000 medical providers, 6,000 hospitals, 110,000 dental providers. Dependent Coverage Medical: Covers dependent to age 26. Dental: Covers dependent to age 19, to age 25 if full-time student. DENTAL PLANS Medical & hospital providers half the size of the self-funded plan. Only local providers. Medical: Covers dependent to age 26. Dental: Covers dependent to age 19, to age 25 if full-time student. Medical & hospital providers half the size of the self-funded plan. Only local providers. Medical: Covers dependent to age 26. Dental: Covers dependent to age 19, to age 25 if full-time student. Delta Dental Plan Guardian Dental Plan MVP Dental Coverage In-Network: Preventative (spacers, prophylaxis, etc.) 20% co-insurance. Basic (fillings, extractions, etc.) 20% co-insurance. Major (periodontal, crowns, etc.) 20% co-insurance. MEMBER CAN GO TO ANY DENTIST ANNUAL LIMIT - None Out of Network Deductibles: $200 per person $400 family maximum No Orthodontics In-Network: Preventative (spacers, prophylaxis, etc.) 100% coverage Basic (fillings, extractions, etc.) 20% co-insurance. Major (periodontal, crowns, etc.) 50% co-insurance. Out of Network: Basic (fillings, extractions, etc.) 50% co-insurance. Major (periodontal, crowns, etc.) 75% co-insurance. MEMBER CAN GO TO ANY DENTIST ANNUAL LIMIT $2,000 per member No Orthodontics Fee schedule with balance billing to member. MEMBER CAN GO TO ANY DENTIST ANNUAL LIMIT $1,500 per member No Orthodontics

Your Plan: Anthem Gold HMO 500/20%/5000 Your Network: California Care HMO This summary of benefits is a brief outline of coverage, designed to help you with the selection process. This summary does not

This is only a summary If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at wwwmvphealthcarecom or by calling 1-877-742-4181 Important

This is only a summary If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at wwwmvphealthcarecom or by calling 1-888-687-6277 Important

Evraz Oregon Steel Comparison of Benefits 2010 MEDICAL This summary is an overview only. The terms and conditions of the benefits described in this guide are determined solely by Health Plan Summary Plan

This is only a summary If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at wwwmvphealthcarecom or by calling 1-888-687-6277 Important

This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at www.chpstudent.com or by calling 1-800-633-7867. Important

Small Group Agility MS200 Coverage Period: Beginning on or after 01/01/2015 This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or

This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at www.state.nj.us/treasury/pensions/health-benefits.shtml or

This is only a summary If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at wwwmvphealthcarecom or by calling 1-888-687-6277 Important

PPO Schedule of Payments (Maryland Small Group) National PPO 1000 The benefits outlined in this Schedule are in addition to the benefits offered under Coventry Health & Life Insurance Company Small Employer

CEMENT MASONS HEALTH AND WELFARE TRUST FUND FOR NORTHERN CALIFORNIA RETIRED CEMENT MASONS AND THEIR ELIGIBLE DEPENDENTS EFFECTIVE JANUARY 1, 2015 GENERAL When You Can Change Plans Type of Plan, Service

This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at www.anthem.com or by calling 1-877-453-5645. Important Questions

This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at www.anthem.com or by calling 1-866-236-4365. Important Questions

This is only a summary If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at wwwmvphealthcarecom or by calling 1-877-742-4181 Important

Small Group Agility MG100 Coverage Period: Beginning on or after 01/01/2015 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual + Family Plan Type: POS This

Your Plan: Anthem Gold PPO 500/20%/4500 Your Network: Prudent Buyer PPO This summary of benefits is a brief outline of coverage, designed to help you with the selection process. This summary does not reflect

COMPARISON OF BENEFITS* FOR CITY OF EUGENE AFSCME-REPRESENTED EMPLOYEES Effective July 1, 2016 Medical/Vision/Pharmacy coverage is administered by PacificSource Health Plans Dental coverage is administered

This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at www.healthreformplansbc.com or by calling 1-866-253-8885.

This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at www.arcsvs.com or by calling 1-877-309-2955. Important Questions

This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at www.state.nj.us/treasury/pensions/health-benefits.shtml or

This comparison is only a summary of benefits. Benefits will be administered as described in each plan s Summary of Benefits & Coverage. For further details, refer to those documents or call Wellmark Blue

This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at www.westernhealth.com or by calling 1-888-563-2250. Important

This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at www.anthem.com or by calling 1-800-445-7490. Important Questions

This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at www.anthem.com/ca or by calling 1-855-333-5730. Important

Evraz Claymont Steel Comparison of Benefits 2010 MEDICAL - Claymont This summary is an overview only. The terms and conditions of the benefits described in this guide are determined solely by Health Plan

This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at www.chpstudent.com or by calling 1-800-633-7867. Important

1/1/2015-12/31/2015 This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at www.paramountinsurance company.com or

2015 Medical Plan Summary AVMED POS PLAN This Schedule of Benefits reflects the higher provider and prescription copayments for 2015. This is not a contract, it s a summary of the plan highlights and is

This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at www.anthem.com/ca/sisc or by calling 1-800-825-5541. Important

This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at http://www.whyviva.com/memberaccess.aspx or by calling 1-800-294-7780.

This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at www.healthreformplansbc.com or by calling 1-866-253-8885.

PPO Kaiser Permanente For Non-PPO Providers Employee Premium None None None None None Explanation of s and Options Available to You If you choose a doctor who is not contracted with Anthem Blue Cross the

This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at www.healthreformplansbc.com or by calling 1-866-253-8885.

HMO Blue New England Enhanced Value Coverage Period: on or after 01/01/2015 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual and Family Plan Type: HMO This

This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at www.healthreformplansbc.com or by calling 1-855-586-6960.

AVMED POS PLAN This Schedule of Benefits reflects the higher provider and prescription copays for 2015. This is not a contract, it s a summary of the plan highlights and is subject to change. For specific

Employee Premium None None None None None Explanation of Plans and Options Available to You Deductible Annual Out-of-Pocket Calendar Year (Applicable to members who reside in California & Nevada Only.)

Your Plan: Anthem Bronze PPO 5500/30%/6450 w/hsa Your Network: Prudent Buyer PPO This summary of benefits is a brief outline of coverage, designed to help you with the selection process. This summary does

MICHIGAN CATHOLIC CONFERENCE January 2015 Benefit Summary This is intended as an easy-to-read summary and provides only a general overview of your benefits. It is not a contract. Additional limitations

This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at https://www.capbluecross.com/sbcsia or by calling 1-800-730-7219.

This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at www.healthreformplansbc.com or by calling 1-866-253-8885.

This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at www.anthem.com or by calling 1-800-445-7490. Important Questions

Important Questions This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at www.state.nj.us/treasury/pensions/health-benefits.shtml

This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at www.healthreformplansbc.com or by calling 1-866-253-8885.

Health First Health Plans : Large Group HMO 250 D Coverage Period: On or after 01/01/2015 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Members Only Plan Type: HMO

This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at www.healthreformplansbc.com or by calling 1-844-241-0208.

This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at www.healthreformplansbc.com or by calling 1-855-586-6960.

This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at www.talltreehealth.com or by calling 1-877-453-4201 Important

This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at www.nhp.org or by calling Customer Service at 1-866-414-5533

Who is eligible to enroll in the Plan? All State of Michigan Employees who reside in the coverage area determined by zip code. All State of Michigan Employees who reside in the coverage area determined

This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at www.etf.wi.gov or by calling 1-877-533-5020. Important Questions

Health Alliance Plan Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage Period: 01/01/2015-12/31/2015 Coverage for: Individual Family Plan Type: HSA HMO This is only a summary.

Kaiser Permanente: KP CA Silver 1250/40 Coverage Period: Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Plan Type: HMO This is only a summary. If you want more detail

Personal Alliance 3000 Silver OFF Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage Period: 01/01/2016-12/31/2016 Coverage for: Individual / Family Plan Type: HMO This is

This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at www.healthfirstny.org or by calling 1-888-250-2220. Important

Deductible Applies - $100 for Single and $200 for Family (Deductible does not apply to any 100% coverage) (Not Available for Meet & Confer Group) Deductible Out of Network Only - $250 for Single and $500

Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual/Family Plan Type: PPO What is the overall deductible? This is only a summary. If you want more details about